NRC Form 313 Application for Materials License

NRC FORM 313

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)
10 CFR 30, 32, 33, 34
35, 36, 37, 39, and 40

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0120

Estimated burden per response to comply with this mandatory collection request: 4.3 hours. Submittal of the
application is necessary to determine that the applicant is qualified and that adequate procedures exist to
protect the public health and safety. Send comments regarding burden estimate to the FOIA, Privacy, and
Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001,
or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory
Affairs, NEOB-10202, (3150-0120), Office of Management and Budget, Washington, DC 20503. If a means
used to impose an information collection does not display a currently valid OMB control number, the NRC may
not conduct or sponsor, and a person is not required to respond to, the information collection.

APPLICATION FOR MATERIALS
LICENSE

INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES (“CONSOLIDATED GUIDANCE ABOUT MATERIALS
LICENSES”) FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1556/.
SEND TWO COPIES OF THE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.
APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH:

IF YOU ARE LOCATED IN:
ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND
APPLICATIONS TO:

MATERIALS SAFETY LICENSING BRANCH
DIVISION OF MATERIAL SAFETY, STATE, TRIBAL AND RULEMAKING PROGRAMS
OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS
U.S. NUCLEAR REGULATORY COMMISSION
WASHINGTON, DC 20555-0001

MATERIALS LICENSING BRANCH
U.S. NUCLEAR REGULATORY COMMISSION, REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:
IF YOU ARE LOCATED IN:
ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA,
KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY,
NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, SOUTH
CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST VIRGINIA,
SEND APPLICATIONS TO:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS,
LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH
DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS,
UTAH, WASHINGTON, OR WYOMING,
SEND APPLICATIONS TO:

LICENSING ASSISTANCE TEAM
DIVISION OF NUCLEAR MATERIALS SAFETY
U.S. NUCLEAR REGULATORY COMMISSION, REGION I
2100 RENAISSANCE BOULEVARD, SUITE 100
KING OF PRUSSIA, PA 19406-2713

NUCLEAR MATERIALS LICENSING BRANCH
U.S. NUCLEAR REGULATORY COMMISSION, REGION IV
1600 E. LAMAR BOULEVARD
ARLINGTON, TX 76011-4511

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS
AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S.NUCLEAR REGULATORY COMMISSION JURISDICTIONS.
2. NAME AND MAILING ADDRESS OF APPLICANT (Include ZIP code)

1. THIS IS AN APPLICATION FOR (Check appropriate item)
A. NEW LICENSE
B. AMENDMENT TO LICENSE NUMBER
C. RENEWAL OF LICENSE NUMBER
3. ADDRESS WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED

4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

BUSINESS TELEPHONE NUMBER

BUSINESS CELLULAR TELEPHONE NUMBER

BUSINESS EMAIL ADDRESS

SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.
5. RADIOACTIVE MATERIAL

6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.

a. Element and mass number; b. chemical and/or physical form; and c. maximum amount
which will be possessed at any one time.

7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR
TRAINING AND EXPERIENCE.

8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.

9. FACILITIES AND EQUIPMENT.

10. RADIATION SAFETY PROGRAM.

11. WASTE MANAGEMENT.

12. LICENSE FEES (Fees required only for new applications, with few exceptions*)
(See 10 CFR 170 and Section 170.31)
*Amendments/Renewals that increase the scope of the existing license to a new or higher fee category will require a fee.

FEE
CATEGORY

AMOUNT
ENCLOSED

$

13. CERTIFICATION. (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING
UPON THE APPLICANT.
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE APPLICANT, NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN
CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35 , 36, 37, 39, AND 40, AND THAT ALL INFORMATION CONTANED HEREIN IS TRUE AND
CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF.
WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 25, 1948 62 STAT. 749 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO
ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
CERTIFYING OFFICER -- TYPED/PRINTED NAME AND TITLE

DATE

SIGNATURE

FOR NRC USE ONLY
TYPE OF FEE

FEE LOG

FEE CATEGORY

AMOUNT RECEIVED

CHECK NUMBER

$
APPROVED BY

NRC FORM 313 (MM-YYYY)

DATE

COMMENTS